Hospital and Surgeon Report Cards in California – Focus on CABG Surgery

1. Hospital and Surgeon Report Cards in California – Focus on CABG Surgery Joseph Parker, Ph.D. Manager, Healthcare Outcomes Center, Office of Statewide Health Planning and Development 5/15/2012

2. Presentation Outline • LEGISLATIVE/OSHPD HISTORY OF OUTCOMES REPORTING IN CALIFORNIA • CALIFORNIA CABG OUTCOMES REPORTING PROGRAM (CCORP) DESCRIPTION • KEY ISSUES IN PUBLIC REPORTING and ISSUES SPECIFIC TO SURGEON REPORTING • IMPACT OF PUBLIC REPORTING • OTHER AREAS OF RESEARCH & ANALYSIS • Evaluation of Post-Operative Stroke for Hospital Public Reporting (Time permitting)

3. Public Reporting: Supporting Arguments • Quality reporting will help consumers make more informed healthcare decisions and provide payers and employers with information to help them spend their healthcare dollars more effectively (value-based decision making) • Outcome reports improve the quality of healthcare by providing greater transparency about hospital/surgeon outcomes (media, reputation) • Enables providers to benchmark their performance and direct internal quality improvement activities • Data may enable some QI activities • Enables review of cases with possible care issues • Brings to light data quality issues

4. OSHPD IN THE CALIFORNIAGOVERNMENT HIERARCHY Governor Health & Human Services CPHS Mental Health OSHPD Health Care Services Public Health EMSA MRMIB Other CHHS Departments: Aging, Alcohol and Drug Programs, Child Support Services, Community Services and Development, Developmental Services, Social Services, and Rehabilitation Non-CHHS Health Departments: Managed Health Care, Corporations, Consumer Affairs, Patient Advocate

5. Legislative History of OSHPD’s Quality Reporting Programs • Most directed at OSHPD patient discharge data • AB 524 – 1991: Established current hospital risk-adjusted mortality public reporting program • SB 1973 – 1998: Allowed OSHPD to add clinical data to discharge data to improve risk models for outcome reports • Reports on heart attack, community acquired pneumonia, and ICU mortality produced – working on stroke and hip fracture • AHRQ Inpatient Mortality Indicators

6. CCORP Reports • Last two reports: 2007-2008, 2009

7. CCMRP: Limitations • Voluntary participation (approx. 70% of hospitals) • Lack of data on non-participants • Suspected that non-participants were poorer performers • Hospitals could withdraw after seeing preliminary results • Stakeholder Insistence on statewide reporting • If New York, Pennsylvania, New Jersey are doing it, why can’t California? • Voluntary program demonstrated that scientifically valid quality reporting was possible

8. Legislation: Senate Bill 680 (2001) Created mandatory data reporting program, California CABG Outcomes Reporting Program (CCORP) for all California licensed hospitals that perform heart bypass surgery Program Elements: • Risk-adjusted results to be reported by hospital (every year) and by surgeon (every two years) • Hospital and surgeon data review process • Surgeon “appeals” process to contest ratings • 9-member Clinical Advisory Panel (CAP) with 4 surgeons • Annual hospital data audits

9. Coronary CABG Outcomes Reporting Program (CCORP) • First year of data collection 2003 • Data collected on ALL CABG surgeries, but outcomes reporting only on isolated CABG (for now) • Surgeon certification of final data • Hospital penalty for late filings ($100 per day) • Extensive data quality activities

10. Ensuring Data Quality and Integrity • Hospital data abstractor training • Clinical consultation on coding issues • CCORP expert cardiologist, UC Davis cardiologists • Online data submission with automated edits • Quality comparison reports (statewide vs. hospital) • Required medical chart documentation for some conditions (op report, etc.) • Linkages to Patient Discharge Data and Death File • Yearly hospital medical chart audits & auditor training

11. Hospital Medical Chart Audits • Audit Approach • Preliminary hospital and surgeon outliers • Near hospital and surgeon outliers • Hospitals with probable over-reporting of important risk factors • Hospitals from a random pool • All deaths, post-op strokes and higher-risk patients • Number of records proportional to hospital size • Blinded on-site medical chart audits by cardiac nurses with cardiologist over-reads • Audit results provided to hospitals to improve coding • Audit data replaces submitted data

12. 2008 Audit Sample - Design • 18,042 CABGs at 120 hospitals / 264 surgeons • 14,043 isolated; 3,999 non-isolated CABGs • Audit outlier and near-outlier hospitals/surgeons (isolated or non-isolated CABGs) • Audit hospitals with coding issues • Audit random hospitals • Total # of hospitals for audit • Total 2593 records audited (approx. 14% all CABGs) • Cost: Approx. $500,000 N=21 N=10 N=5 N=36

13. Key 2008 Audit Findings - Coding of Risk Factors

14. Coding Quality in CCORP Audits 2003-2007 0.50 Mitral Insufficiency 0.25 0.68 MI Timing 0.56 0.58 Number of Diseased Vessels 0.49 0.47 NYHA Class IV 0.25 0.92 0.89 IMA Use

15. Preliminary Report Results • Hospitals (60 day review) • Preliminary risk-adjusted mortality rates for all hospitals • Performance ratings – worse-, better-, or not different- than state average • Instructions on how to submit a comment letter for final report • Surgeons (30 days to appeal) • Preliminary risk-adjusted results for only that surgeon • Performance rating – worse-, better-, or not different- than state average • Instructions on how to appeal if “results do not accurately reflect the quality of care provided”

18. Audit Effect on Hospital Outlier Status (N Hospitals = 120)

19. Surgeon “Appeal” Process • Surgeons submit statements and supporting documentation • OSHPD reviews statements and agrees or disagrees with surgeon request • Surgeons not satisfied with OSHPD decision can forward statement to Clinical Advisory Panel for review • Panel will: • Uphold the OSHPD decision OR • Reach one of the other conclusions set forth by the law • Flaw in the risk model so report is flawed (correct or don’t release) • Flaw in surgeon data so corrections required • Panel’s determination is final

20. Surgeon Statement Process • 2003-2004 Report • 31 Statements - 15 forwarded to Panel • Panel did not agree with OSHPD on 8 cases, allowed resubmission of data for 6 • 3 surgeons’ performance ratings changed as a result of review process • 2007-2008 Report • 9Statements – 5 forwarded to Panel • Panel concurred with all OSHPD decisions • Issues • Very high-risk patients/rare serious conditions (risk model inadequate) • Refusal of blood products (e.g., Jehovah’s Witness) • Non-isolated vs. isolated CABG assignment • Assignment of responsible surgeon

21. Current Report Contents • Performance ratings (“worse” than, “better” than, or same as state average) for hospitals and surgeons on isolated CABG surgeries • Hospital performance ratings for post-operative stroke and readmission w/in 30 days after isolated CABG surgery • Hospital performance ratings for use of the Internal Mammary Artery • Only low (poor) usage hospitals given performance rating • Hospital/Surgeon volume and outcome(s) associations • Statewide trends in CABG and PCI volumes and mortality

22. Impact of CABG Report • Hospitals have instituted internal QI programs • Reported changes in hospital contracting/referrals, especially after release of surgeon reports • Surgeons more involved in the data quality review • In-hospital mortality rates have declined 36% since start of mandatory program • UC Davis preliminary report on “Impact of Mandatory Public Reporting” • Marked and sustained drop in observed and risk-adjusted operative mortality • No detectable avoidance of high-risk patients

23. Expected Operative Mortality by Quarter

24. Risk-adjusted Operative Mortality by Quarter

25. Volume of Isolated CABG, Non-Isolated CABG, and PCI Surgery in California 1997-2010

26. In-Hospital Mortality Rates for Isolated CABG, Non-Isolated CABG, and PCI Surgery in California 1997-2010

27. Observed Isolated CABG Inpatient Mortality Rates for CA and other Reporting States (1996-2010)

28. OTHER CABG REPORTING ISSUES • Internal Mammary Artery Usage • 92% in 2005 vs. 96% in 2009 • 7 “low” outliers in 2005 vs. 5 in 2009 • Volume – Outcome Relationship • Sometimes significant but weak at hospital level • Generally significant but not strong at physician level (hierarchical linear modeling used for analysis) • No longer part of public report • CABG Volume Vs. PCI Volume • The relevance of CABG reporting with dwindling volume • Importance of reporting PCI outcomes

29. OTHER OUTCOMES REPORTING ISSUES • Operative vs. 30-day Mortality (fairness to teaching/public hospitals) • Appropriateness of care – CABG vs. PCI vs. medical treatment • Complications • Composite measure issues • Logistic regression vs. hierarchical linear models • Issue of small volume hospitals • Issues around interpretability of results • Parsimonious vs. more complete risk models